Sunday, October 30, 2005

This just in....

There are few things that newFNP likes to ponder less than pelvic floor disorders and urinary incontinence. I was, however, at a conference recently and found myself desperately and vigorously performing Kegel after Kegel in order to stave off a sad, sad future. In fact, I'm doing my Kegels now and you should be too. We should all have the lactic acid build-up normally associated with leg presses, 10-mile runs and push-ups. Because, baby, I do not want my uterus heading south for the winter. Nor am I relishing the thought a future with rubber mattress pads.

The reason I am exercising my vagina 100 times more than my abs or glutes is that the keynote speaker at the conference presented data from the WHI that stated that a full forty-frigging-one percent of women had some form of prolapse. Hey, maybe your bladder is just sneaking posteriorly into your vag, but maybe your cervix is at your knees. I don't want either. Kegel, Kegel, Kegel... feel the burn.

Sure, childbirth makes a difference in the likelihood of anatomical slippage, but guess what? It's the first kid that makes the most difference and, I hate to say it, but nulliparous women may share the prolapse experience with their more fertile sisters. Thinking of scheduling a c-section like your gal-pal Britney S.? Well, that's not gonna save you either. So go ahead and have your babies in whichever way you choose, but Kegel it up, ladies. And do your best to lose the pregnancy weight, because overweight (waist circumference >88cm) isn't going to help matters.

The same goes for incontinence. Parity, obesity, hysterectomy... they all will have you running to bathroom, stifling your laughs and hoping that your little cough goes away quickly. Apparently, 50% of us will have incontinence. Son of a bitch, does that ever suck. Kegels. 30-35 exercises per day. I don't want vaginal hypertrophy, but I'm thinking the more, the merrier when it comes to incontinence prevention.

Diabetes also plays a role in incontinence due to the nerve damage. So, let's see what sucks about uncontrolled diabetes. It's not the death so much, in my opinion, as all the horrible effects of the disease. Blindness, kidney dysfunction, erectile dysfunction, amputations, thick toenails, heart disease and incontinence. None of those are my idea of a good time.

In other news, updated CDC guidlelines, due to come out next year, state that we should no longer be prescribing 2g of Flagyl PO for BV. It's just not efficacious. It's all about the 500mg PO BID x 7, 5 nights of Metro-Gel or 7 nights of Clindamycin cream. So give your ladies a break and treat their BV effectively, OK?

Wednesday, October 26, 2005

Melting

NewFNP is somewhat cynical. Dry. You know the type. Not someone easily moved by cuteness.

However, newFNP is not made of stone. Today a little girl, around age 7, was at the clinic with her mom, who had an appointment. After I had finished the appointment, which involved tears, labs, referrals and the ED, the little girl grabbed my hand in hers, kissed it and said, "Thank you for helping my mommy."

It was the best moment of my life as newFNP.

Sunday, October 23, 2005

One for you, one for me

NewFNP loves to share. Lip gloss, fashion advice, tricks of the trade - all fair game. I draw the line at underwear, boyfriends and antibiotics. I'll tell you what - many of my patients share at least one of the latter three.

A patient last week came in with dysuria. She had discussed this problem with a friend who had once had similar symptoms and offered her the cure: a half-used tube of Metro-Gel. Only my patient had no clue cells; only nitrites, leukocytes and blood. Good luck treating that UTI with Metro-Gel, sister. I just have to ask: did her friend think to give her the applicator?

If Metro-Gel was the only shared medication, I would just shake my head, shudder and go on with my life. My patients, however, share the real goods. I'm not talking about percocet here. My patients are crazy for Doxy. Do they want diarrhea and yeast infections?

In Mexico, antibiotics are available over the counter. Great for when Montezuma strikes his E. coli revenge, bad for when you have a headache and decide to take 2 and call no one in the morning. Family member heading to TJ for the weekend? Pick up some doxy - one never knows when one might need it. When did doxycycline become the Mexican aspirin? Screw the 10-day course! It's a 'prn.'

OTC antibiotics are also scary when patients self-treat for an unknown condition. For instance, the patient who has daily forced sex (see Ayyyy me duele!!) has pelvic pain. What a fucking shock. Anyway, she has been treating her pain with Bactrim. For a year.

As clinicians, we are taught to use antibiotics judiciously and I am Scroogy McScrooge with my prescriptions. I am the asshole who will not give your 3-year old Amoxicillin for her ear infection. As I have learned in the past couple of months, however, focusing on clinician behaviors misses a huge component of the problem: people who self treat and inadvertently misuse antibiotics. Hi MRSA, hi C. diff.

This is a public health campaign waiting to be developed. You heard it here first. All we need are a bunch of fat, insulin resistant 12-year olds running around with MRSA, having unprotected anal sex and smoking cigarettes.

OK, probably not the cigarettes. Public health did a nice job on that one. Fight the power, public health. Fight the power.

Monday, October 17, 2005

Social history

There are certain questions that I have not once asked any of my health care providers. These questions include:

1) Are you married or single?
2) Do you have any kids?
2a) Why not?

My patients, however, ask me these questions with astonishing frequency. I'm talking daily to multiple times daily. On Friday, I'm quite certain that a record was set. If I had to hazard a guess, I'd say that fully 40-50% of my patients asked one or more of the previous questions. One older gent went on to ask, "What kind of men do you like: Mexican or American?"

He then offered this little bit of dating advice. "You know what you should do?" he said. "Go to dances." This is the same exact advice that my grandmother gives me, wistfully thinking back to the WW2 era dances, one of which she attended and met my grandfather. I told him what I tell her: I don't like dancing. Why would I want to meet someone who does? I'm sure that I can find many ways to disappoint the man of my dreams and I don't need to add fuel to the fire with the ole "I like to dance" bait & switch routine. I like to read. I like to sit on my couch, drink French Roast, and read. I meet a disappointing number of hot, smart, funny guys (n=0) conducting this activity.

So, yes, my patients frequently ask me about my personal life. And, going against what my professors might counsel, I answer them - mostly. I don't tell them that I don't think I want kids because my sense it that is akin to telling them that tortillas aren't breakfast food for me, or that I have no interest in soccer (or any other sport except mine for that matter). I think it's appropriate to share to the extent we are comfortable with our patients. Part of why I am an NP is to remove barriers to patient care. I hope that my being a person and not just a fucking hot-ass girl in a white coat will facilitate that. I want to build relationships with my patients in an effort to keep them healthy and to keep them satisfied with the care they receive at our clinic.

Plus, it's like having a nice Jewish family, meddling in my personal life, right here in the midst of my Latino patient population. L'chaim!

Friday, October 14, 2005

Diamonds

In school, we often receive 'pearls' about patient care. NewFNP is more of a diamond type of girl. A little flashier, a little less 1950's housewife. So I'll offer a couple of diamonds from my week.

1 carat: When you have a patient with a low hemoglobin (see 'I hate it when I'm stupid'), re-check the measuremrent in no more than a week. One reading doesn't tell you if they are actively bleeding, but if the result drops then you know that something is rotten in Denmark. Sure, this seems utterly common-sensical, but sometimes when you are new, even the most pedestrian of logical thought processes eludes you. I'm sure you all smarter than me, however....

2 carats: I am screening so frequently for depression and having so many patients disclose that they are depressed. That is not the diamond; just hang on a second. The reason I am screening so much is that I realized that a lot lot lot of my patients had non-specific complaints and an affect that bugged the shit out of me. Now, newFNP understands that that is neither replicable nor sensitive, but the truth smarts at times. So these patients bug, baby, bug. I can't find anything wrong with them, which definitely has the potential to be chalked up to my new-ness. However, I started to think that the headache, back pain, abdominal pain and bone pain, coupled with 10+ annoyingness might be something else. I swear, I pose the question, "Do you think you are depressed?" and watch out! Grab your galoshes and rain caps because the water works start. Then, of course, I feel like a big fucking asshole for my insensitivity and for being annoyed with them in the first place. *I* was the problem, after all, or at least part of the problem. It did, however, reinforce that I need to truly be aware of mental as well as physical health screening *and* that I need to need to trust my instincts.

No more diamonds! Except for Boston FNP, who should check out "The Girl's Attractive" by Diamond Nights.

Picky evolution

NewFNP is no proponent of intelligent design. Anyone who has taken a college-level biology class can understand why when you think back to the markings on animals, moths, insects, etc. Others may remember that from high school, but newFNP had biology 1st period and was no fan of 7:50AM classes. It's true, newFNP was a big 1st period ditcher. Anyway...

One of my non-scientific proofs of the theory of evolution is that I understand the desire to pick. Have we all seen the PBS shows in which the mommy gorilla picks crap off of the baby gorilla? I loooooooove picking. It's gross, but true.

I began to understand the process of natural selection and its relationship to picking this week in clinic. This understanding has made me think twice about my love affair with the pick. Here is a mathematical equation to explain what I saw this week:

folliculitis + (machinist + greasy, dirty hands) + picking = 2(abscess)

And the funny thing... what did he call it? A rash. Noooo, not a rash my friend. A pus pocket, a purulence pond, a perilous post-picking problem.

Must. Keep. Hands. Off. Blemishes. Bumps. Et cetera.

Tuesday, October 11, 2005

Ayyyyy me duele!!

Culture. We all have it. In mine, stoicism in the face of pain - emotional or physical - is valued. I'm not saying that's right, I'm just laying it out there. Apparently, an ever-elusive perfect weight is valued as well as newFNP's family always has a comment about weight during any visit - too much, too little, but not-as-of-yet just right. Anyway, internal demons aside, newFNP is one to grin and bear it, pull herself up by her bootstraps - bootstraps which will one day bear the Prada insignia if all goes well.

This cultural bias and placement makes it exceedingly difficult for newFNP to stomach the (perceived) histrionics of pain during exam. The vocalization of "Ayyyyyy, me duele.... aqui, ayyyy me duele!! Doctora, me duele!!! Ayyyyy, dios mio, me duele!!" It makes me crazy. I don't doubt that it hurts, but I would have to be carrying my own detached arm to the doctor to complain half as much as these women do. A good fashionista pal pointed out that perhaps some of these women have no other place to vent their pain - a good hypothesis, I believe.

Cultural bias takes on other forms as well. Today, a 40-year old patient came in for a pap. She had sex last night - no condom. Generally, no condom = no pap, but her case was different. This woman has had sex virtually every day for the past 26 years with her husband, whether she wanted to or not. According to her, she "rarely" wants to. According to him, it's her responsibility. Even though she complies with this, again, nearly daily activity, her husband has had many extra-marital relationships and has, according to my patient, transmitted chlamydia, gonorrhea, herpes and pubic lice to her throughout the course of their relationship.

How is that for insult to injury? Sexually transmitted infections through forced sex. Incidentally, she denies IPV. Hmmm..... can you see where newFNP's culture is sneaking in?

I asked her if she thought it was okay for her to have sex with her husband when she didn't want to. She responded, "No se." If she doesn't know, how am I supposed to know? I know what the answer is for me, but is this a universal truth or a newFNP truth? Her affect and her tears told me what she really believes, but I could only offer her the tools available to us: our counselor.

I am so glad I got to come home to my apartment, no abuse, maple yogurt and Boston Legal on the tube. I wonder what her night will be like.

Incidentally, in the area where my clinic is located, I have noticed a cultural value of slow-assed fucking driving. Ayyyyyyy, me duele, the slow drivers. Mueve!

Saturday, October 08, 2005

I hate it when I'm stupid

I think that when I'm overwhelmed, I have that whole "forest through the trees" problem. I saw a patient this week (several times) who I diagnosed with Type 2 Diabetes. Her blood sugars were in the 3- and 400's. I was diligently attempting to decrease this number when I noticed that she also had a Hgb level of 6.3. I provided the following to her:

  • diabetes education regarding meds, sequelae, dietary changes, exercise
  • prescriptions for appropriate meds and insulin in the office
  • Ferrous sulfate 325 mg/day
  • referral for colonoscopy
  • stool cards x3

And, in all of that, I also provided utterly inadequate care. Why? I didn't get a fucking CBC! How did I miss that? Total cholesterol? Check. Hgb A1c? Check. CBC? Nope, not so much. Ugh! Why am I still a jackass? The beauty is that every time I feel like an ass, I know that the shame of missing something so easy will cause me to never make that rookie mistake again. And I am a rookie, after all. I just don't like to play like one.

Wednesday, October 05, 2005

Achy Breaky Heart

A crazy thing happened today. I saw the most patients I have ever seen in a single day (n = 28) and I left the clinic at 5:00 PM on the nose. It was divine. I am in a state of joy bordering on beatitude.

I did, however, send a patient to the emergency room. I like to have both the calm and the storm, I guess. Here is why this man had a ride with the paramedics. He had chest pain, dyspnea (worse when supine, so I guess technically it was orthopnea) and had diagnosed left-sided heart failure last year that resulted in him receiving a pacemaker. His father died from heart failure at age 54. And did I mention that, despite treatment with 80mg TID of Lasix, he had urinated exactly once (4 ounces – he actually measured) in 48 hours?

Now, I must confess that I partially sent him because I was scared, the only provider in the office this afternoon, and I knew that his history and symptoms were both serious and beyond my ability to care for. I think that it was the right decision. He was overweight and his exam was unremarkable, but as I’ve previously mentioned, ausculatory exams on obese persons are exceedingly difficult. Did I hear crackles? I did not. Nor did I hear normal breath sounds; I heard faint breath sounds and faint heart sounds. His abdomen was huge. Was he holding fluid in there? I don’t know, but the doctors at the emergency room will.

For those students/new practitioners who are familiar with the lower extremity edema/DOE/chest pain presentation of heart failure, please allow me to point out that this picture often points to right-sided failure. Left-sided HF is sneakier. I was too freaked out to think about that until the paramedic mentioned it, leaving me to feel like a huge jackass. Whatever – my ego will survive and I am the wiser for it.

Here are some tidbits to refresh and/or inform:

Signs of HF include:
DOE/PND/orthopnea
Cough with or without frothy sputum (yeah – gross)
Abdominal pain +/- nausea
Constipation (who knew??)
Exercise intolerance (I’d hazard a guess that 90% of my patients have this as they never exercise)

Symptoms of HF include:
Fine crackles, generally bibasilar
S3
Edema
JVD
Tachycardia
Hepatomegaly
Pallor or cyanosis

However, Uphold & Graham point out that “[in] left-ventricular systolic dysfunction, signs and symptoms are not reliable indicators or cardiac functioning; patients with severely impaired ventricular performance may be completely asymptomatic until they overexert themselves…” Thus, the ED visit today.

Which reminds me… the paramedic asked me, as I was standing there feeling like a buffoon, if any of the patient’s medications were constipating. A) I don’t fucking know for certain but probably not and B) constipated or not, homeboy has essentially not taken a leak in 2 days and has both a personal and family history of cardiac disease. Can we deal with the poop later, please? When I’m thinking of priorities, it goes something like this:
1) heart failure
2) poop

Twenty-eight patients. I think my days on easy street will be coming to an end. I exceeded my goal – set by the clinic manager - of 22-25 patients/day. Crap.